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Normal Personality Development and Personality Disorders

Janet E. Johnson, MD, MPH Tulane University School of Medicine

Department of Psychiatry and Behavioral Sciences

Learning Objectives

 Be able to describe the various personality disorders

 Be able to apply the personality disorder categories to patient scenarios

Personality

  Defined as the totality of emotional and behavioral traits that characterize the person in day-to-day living under ordinary conditions.

  Usual manner of thinking, feeling, behaving and relating to others

  Relatively stable and predictable.   Blend of inborn temperament, genetic strengths

and vulnerabilities, and impact of positive and negative life experiences.

Normal Personality Development

  Second half of 1st year: attachment   Internalization: mechanism for building

psychological structure   Stable pattern of a child’s temperament

becomes established during second year.   Nature versus nurture?   Behavioral genetics revealing pervasive genetic

influences on normal and abnormal personality.

What is Normal?

 Who’s to say?  Circumstances, culture/sub-culture,

setting/location, timing, age

Who’s Normal?

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Who’s Normal? Personality assessment

 Meyers-Brigg  Five Factor Model  Cloninger’s Seven-Factor Model  Biogenic Spectrum Model

Myers Brigg

 Questionnaire designed to measure psychological preferences in how people perceive the world and make decisions.

 Widely utilized  Extrapolated from Jung’s theories.  Two pairs of cognitive functions:

  Rational functions: thinking and feeling   Irrational functions: sensing and intuition

Dichotomies

 Extraversion (E) – (I) Introversion  Sensing (S) – (N) Intuition  Thinking (T) – (F) Feeling  Judgment (J) – (P) Perception

 16 possible types   Example: ESTJ

Five Factor Model

 Neuroticism (anxiety, depression, vulnerability, hostility)

 Extraversion (warmth, assertiveness, activity, gregariousness)

 Openness (feelings, fantasy, ideas, values)

 Agreeableness (trust, altruism, modesty)

 Conscientiousness (dutifulness, self- discipline, deliberation)

Seven-Factor Model of Temperament and Character  Harm avoidance  Reward dependence  Novelty seeking  Persistence  Character factor  Self-directedness  Cooperativeness  Self-transcendence

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Temperament Factors (harm avoidance, reward dependence, novelty seeking, persistence

  Independently heritable  Manifested early in life   Involved in perceptual memory and habit

formation  Associated with biologic features

  Novelty seeking decreased dopaminergic activity   Harm Avoidance -> high serotonergic activity   Reward dependence low noradrenergic activity

Personality Disorders

  A personality disorder is a variant of those character traits that goes beyond the range found in most people.

  When personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress they constitute a class of personality disorder.

  Patients with personality disorders show deeply ingrained, inflexible, and maladaptive patterns of relating to and perceiving both the environment and themselves

General Diagnostic Criteria

  An enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture. The pattern is manifested in two or more of the following areas:   Cognition (perceiving and interpreting self, other

people and events)   Affectivity (range, intensity, lability appropriateness

of emotional response)   Interpersonal functioning   Impulse control

General Diagnostic Criteria

  The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

  The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning.

  The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

  The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

  The enduring pattern is not due to the direct effects of a substance or a general medical condition.

Personality Disorders

  More likely to refuse psychiatric help than other psychiatric disorders

  Ego-syntonic   Regarded as unmotivated for treatment   Grouped into three clusters: A, B, C   Other: Not otherwise specified and mixed   Diagnosed on Axis II   Elevated rates of divorce, unemployment,

homelessness, perpetration of child abuse, child custody proceedings, separation

Personality Disorders

  Common in general population   Prevalence of 10-18%   Outpatient 30-50%   Inpatient > 50% co-morbidity

  Males and females equal overall   Etiology

  Genetics   Psychoanalytic theories

 Freud: psychosexual development  Reich: defense mechanisms

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Common Defense Mechanisms   Projection   Splitting   Regression   Fantasy   Dissociation   Intellectualization   Isolation   Reaction formation   Repression   Acting out   Passive aggression

Cluster A: Paranoid, Schizoid, Schizotypal

  Odd, eccentric (“weird”)   Key clinical features: social deficits, absence of

close relationships   Treatment: structure, rehabilitation, support,

medication   Course: stable   Prognosis: poor   Genetics:

  More common in the biological relatives of schizophrenic patients than among control groups.

Paranoid Personality Disorder

  Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

Paranoid Diagnostic Criteria

  Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.

  Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends/associates.

  Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.

  Reads hidden demeaning or threatening meanings into benign remarks or events.

  Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights.

Paranoid Diagnostic Criteria

  Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.

  Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

  Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, or another psychotic disorder, and is not due to the direct physiological effects of a general medical condition.

Paranoid Personality Disorder

  Characterized by long-standing suspiciousness and mistrust of people in general.

  Refuse responsibility for their own feelings; are often angry, hostile, irritable.   Bigot, injustice collector, pathologically

jealous spouse, litigious crank   Prevalence 0.5-2.5 %   Male > female   Differential diagnosis: schizotypal pd,

schizophrenia, delusional d/o   Antipsychotic meds sometimes useful

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Schizoid Personality Disorder

  A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

Schizoid Diagnostic Criteria

  Neither desires nor enjoys close relationships, including being part of a family.

  Almost always chooses solitary activities.   Has little, if any, interest in having sexual

experiences with another person.   Takes pleasure in few, if any, activities.   Lacks close friends or confidents other than

first-degree relatives.   Appears indifferent to the praise or criticism of

others.   Shows emotional coldness, detachment, or

flattened affectivity.

Schizoid Personality Disorder

 1-7.5% of population  Males diagnosed 2x females   Intact reality testing  Most function relatively well, generally do

not require clinical intervention  Psychotherapy treatment of choice

(supportive), but rarely seek treatment  Differential diagnosis: schizotypal pd,

avoidant pd

Schizotypal Personality Disorder   A pervasive pattern of

social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts:

Schizotypal Diagnostic Criteria

  Indicated by five or more of the following:   Ideas of reference.   Odd beliefs or magical thinking that influences behavior

and is inconsistent with sub-cultural norms (superstitiousness, clairvoyance, telepathy).

  Unusual perceptual experiences, including bodily illusions.

  Odd thinking and speech (vague, metaphorical, stereotyped, circumstantial).

  Suspiciousness or paranoid ideation.   Inappropriate or constricted affect.   Behavior or appearance that is odd, eccentric or peculiar.

Schizotypal Personality Disorder   Lack of close friends or confidants other than

first degree relatives.   Excessive social anxiety that does not diminish

with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

  Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder or a pervasive developmental disorder.

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Schizotypal Personality Disorder   Schizophrenia spectrum disorder   Some forms involve biologic abnormalities

characteristic of schizophrenia   Prevalence: 3% of population   Males > females   Approximately 10% commit suicide   Differential diagnosis: schizophrenia, paranoid

pd, schizoid pd, avoidant pd   Low dose antipsychotics may be helpful

CLUSTER B: Antisocial, Borderline,

Narcissistic, Histrionic   B for “bad”   Dramatic, emotional, erratic, “wild”   Key clinical features: social and interpersonal instability   Treatment: support, exploration, sociotherapy, individual

therapy, medication   Course: unstable   Prognosis: some remission with age   Genetics:

  More family members with mood disorders   Group see most frequently in clinical practice

Borderline Personality Disorder   A pervasive pattern of

instability of interpersonal relationships, self-image, and affects, and marked impulsivity by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Borderline Diagnostic Criteria

  Frantic efforts to avoid real or imagined abandonment.   A pattern of unstable and intense interpersonal

relationships characterized by alternating between extremes of idealization and devaluation.

  Identity disturbance: markedly and persistently unstable self-image or sense of self.

  Impulsivity in at least two areas that are potentially self-damaging: (spending, sex, substance abuse, reckless driving, binge eating).

Borderline Diagnostic Criteria

  Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

  Affective instability due to a marked reactivity of mood.   Chronic feelings of emptiness.   Inappropriate, intense anger or difficulty controlling anger

(frequent displays of temper, constant anger, recurrent physical fights).

  Transient, stress-related paranoid ideation or severe dissociative symptoms.

Borderline Personality Disorder   Prevalence: 2-3% of the population   2:1 female:male ratio   Most prevalent personality disorder in all clinical settings

(12-15%)   51% of all inpatients   27% of all outpatients with a personality disorder

  Increased risk for co-morbid mood disorders, eating disorders, substance abuse, PTSD

  Up to 10% will have completed suicide by age 30 years   Increased prevalence of mood disorders in families of

borderline patients

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Borderline Personality Disorder   Usually diagnosed by age 40 years   Course is variable but rarely changes over time   Some patients improve in middle age   Treatment: several modes of psychotherapy

  Dialectical behavioral therapy (DBT)   Instill intense counter-transference

  Differential dx: bipolar disorder, schizotypal pd, histrionic pd, narcissistic pd, dependent pd, psychotic disorders

Antisocial Personality Disorder

  Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more):

Antisocial Diagnostic Criteria

  Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest.

  Deceitfulness, as indicated by repeated lying, use of aliases, conning others for personal profit,pleasure

  Impulsivity or failure to plan ahead.

Antisocial Diagnostic Criteria

  Irritability & aggressiveness, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.

  Lack of remorse, as indicated by being indifferent to, or rationalizing having hurt, mistreated, or stolen from another.

  The individual is at least 18 years old.   There is evidence of conduct disorder with onset before

age 15 years.   The occurrence of antisocial behavior is not exclusively

during the course of schizophrenia or a manic episode.

Antisocial Personality Disorder

  Sociopath, “morally bankrupt”   Disregard for rights of others and lack of

remorse   Prevalence: 3% male; 1% female   Up to 75% of prison population   Occurs 5x more commonly in first-degree

relatives of males with the disorder   Variable course   Differential dx: other Cluster B pd, substance

abuse disorders, mania, mental retardation   Difficult if not impossible to treat

Histrionic Personality Disorder

  A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

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Histrionic Diagnostic Criteria

  Is uncomfortable in situations in which he or she is not the center of attention.

  Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.

  Displays rapidly shifting and shallow expression of emotions.

  Consistently uses physical appearance to draw attention to self.

  Has a style of speech that is excessively impressionistic and lacking in detail.

Histrionic Diagnostic Criteria

 Shows self-dramatization, theatricality, and exaggerated expression of emotion.

  Is suggestible, i.e., easily influenced by others or circumstances.

 Considers relationships to be more intimate than they actually are.

Histrionic Personality Disorder

  2-3% of the population   Females diagnosed more often   Males probably under-diagnosed   Variable course, often softens with age   Treatment is individual psychotherapy   Low dose benzodiazepines are useful for

transient emotional states   Differential dx: dependent pd, borderline pd,

narcissistic pd, somatization disorder

Narcissistic Personality Disorder

  A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Narcissistic Diagnostic Criteria

  Has a grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).

  Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

  Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people.

Narcissistic Diagnostic Criteria

  Requires excessive admiration.   Has a sense of entitlement, i.e., unreasonable

expectations of especially favorable treatment or automatic compliance with his or her expectations.

  Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.

  Lacks empathy, is unwilling to recognize or identify with the feelings and needs of others.

  Is often envious of others or believes that others are envious of him or her.

  Shows arrogant, haughty behaviors or attitudes.

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Narcissistic Personality Disorder   Overwhelming, pathological self-absorption   Primary motivation is power   Prevalence unknown; <1% general population, 2-15%

clinical population   Chronic course   Co-morbid mood disorders common   Aging ultimate blow to self-esteem, prone to severe mid-

life crises   Treatment individual psychotherapy   Do not tolerate group therapy   Differential dx: borderline pd, histrionic pd, antisocial pd

Cluster C: Avoidant, Dependant, Obsessive-Compulsive

  Anxious and fearful, (“wimpy”)   Key clinical features: interpersonal and

intrapsychic conflicts   Treatment: exploration, individual therapy,

group therapy   Course: modifiable   Prognosis: good   Genetics:

  More relatives with anxiety disorders

Avoidant Personality Disorder

  A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

Avoidant Diagnostic Criteria

  Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.

  Is unwilling to get involved with people unless certain of being liked.

  Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.

  Is preoccupied with being criticized or rejected in social situations.

  Is inhibited in new interpersonal situations because of feelings of inadequacy.

Avoidant Diagnostic Criteria

 Views self as socially inept, personally unappealing, or inferior to others.

  Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

 “Pathologically shy”

Avoidant Personality Disorder

  Common, 1-10% of population   Temperament and disfiguring physical illnesses

may be predisposing factors   Males = females   High risk for anxiety disorders   Once assured of acceptance and safety,

respond to virtually all forms of therapy.   Group therapy, SSRIs, anxiolytics   Differential dx: social phobia, dependent pd,

schizoid pd

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Dependant Personality Disorder   A pervasive and

excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Dependent Diagnostic Criteria

  Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.

  Needs others to assume responsibility for most major areas of his/her life.

  Has difficulty expressing disagreement with others because of fear of loss of support or approval.

  Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).

  Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.

Dependent Diagnostic Criteria

  Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself/herself.

  Urgently seeks another relationship as a source of care and support when a close relationship ends.

  Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Dependent Personality Disorder   Prevalence: 2-4% of general population   2.5% of all personality disorders   Females more commonly affected than males   Patients with a history of childhood separation anxiety or

chronic illness may be predisposed   Many patients have co-morbid dysthymia, major

depression and alcohol abuse   Respond well to group therapy, assertiveness training,

social skills training, SSRIs, benzodiazepines   Differential diagnosis: histrionic pd, borderline pd,

avoidant pd, agoraphobia

Obsessive-Compulsive Personality Disorder

  A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts:

OCPD Diagnostic Criteria

  Indicated by four or more of the following:   Is preoccupied with details, rules, lists, organizations, or

schedules to the extent that the major point of the activity is lost.

  Shows perfectionism that interferes with task completion (e.g. is unable to complete a project because his or her own overly strict standards are not met).

  Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).

  Is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).

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OCPD Diagnostic Criteria

  Is unable to discard worn-out or worthless objects even when they have no sentimental value.

  Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.

  Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.

  Shows rigidity and stubbornness.

Obsessive Compulsive PD

  “Anal retentive”   Common in general population, exact

prevalence unknown   Males > females   More common among first-degree relatives with

this disorder   Unlike other personality disorders, these

patients often realize the impact of their behavior and seek treatment on their own

  Group therapy may be very helpful   Differential dx: OCD, narcissistic pd

Other Personality Disorders

  Not otherwise specified (NOS)   Mixed   Depressive personality disorder

  Hippocrates: “black gall”   Negativistic personality disorder

  “passive-aggressive” personality disorder   Self-defeating personality disorder

  Subject of much controversy   Concern it will be applied to victimized and abused

women

Conclusion

 Placed on separate Axis   Indicates unique psychosocial and

treatment considerations  Personality disorders are common  Significant impact on all areas of health

and life  More research need into etiology and

treatment